What is the management plan for an older adult with osteopenia who experiences a traumatic vertebral fracture?

Management of Traumatic Vertebral Fracture in Older Adults with Osteopenia

Even when a vertebral fracture results from trauma in a patient with osteopenia, treat this as a fragility fracture requiring comprehensive osteoporosis management—the trauma simply revealed underlying bone fragility that demands immediate intervention to prevent subsequent fractures. 1

Acute Fracture Management

Immediate Care (First 48 Hours)

• Provide adequate pain relief with regular paracetamol and carefully prescribed opioid analgesia as needed during remobilization. 1
• Ensure appropriate fluid management and correct any postoperative anemia if surgical intervention is required. 1
• Most symptomatic vertebral fractures (approximately 90%) are treated conservatively with analgesics, activity modification, and bracing—only 10% require hospitalization for severe pain. 1
• Consider percutaneous vertebroplasty for patients with severe, refractory pain that limits function, as this provides immediate pain relief in 70-95% of cases and restores vertebral body strength to pre-fracture levels. 2

Multidisciplinary Coordination

• Establish a multidisciplinary clinical system immediately, coordinating between orthopedic surgeons, rheumatologists/endocrinologists, geriatricians (especially for elderly patients), and primary care physicians. 1, 3
• Designate a local responsible coordinator (often a specialized nurse) to identify the patient, organize diagnostic investigations, and initiate osteoporosis treatment. 1, 3

Comprehensive Fracture Risk Evaluation

Every patient aged 50+ with a vertebral fracture—regardless of trauma mechanism—requires systematic evaluation for subsequent fracture risk within 3-6 months. 1

Essential Diagnostic Workup

• Perform DXA scanning of both lumbar spine and hip to measure bone mineral density, as this independently contributes to fracture risk assessment beyond the clinical presentation. 1
• Obtain imaging of the entire spine (T4-L4) via lateral radiographs or vertebral fracture assessment to detect subclinical vertebral fractures, which are present in up to two-thirds of cases and independently predict future fracture risk. 1, 4
• Assess falls risk through detailed history of falls in the past year, followed by specific balance testing when indicated. 1
• Order laboratory evaluation including ESR, serum calcium, albumin, creatinine, TSH, and vitamin D to identify secondary causes of osteoporosis. 1
• Calculate fracture risk using validated tools (FRAX, Garvan, or Q-Fracture) incorporating clinical risk factors: age, gender, BMI, personal/family fracture history, and falls risk. 1

Pharmacological Treatment

Initiate bisphosphonate therapy within 6 months post-fracture to maximize benefit during the period of highest subsequent fracture risk, which remains acutely elevated for 24 months. 3

First-Line Therapy

• Prescribe alendronate 70 mg weekly or risedronate 35 mg weekly as first-choice agents due to proven efficacy in reducing vertebral fractures by 68%, hip fractures by 40%, and non-vertebral fractures by 20%, combined with excellent tolerability, low cost from generic availability, and extensive clinical experience. 1, 3
• Always combine bisphosphonates with calcium 1000-1200 mg/day and vitamin D 800 IU/day supplementation, as this combination reduces non-vertebral fractures by 15-20% and falls by 20%. 1, 3

Alternative Agents

• For patients with oral intolerance, dementia, malabsorption, or non-compliance, use zoledronic acid 5 mg intravenously annually or denosumab 60 mg subcutaneously every 6 months. 1
• For patients with very severe osteoporosis (multiple vertebral fractures or T-score ≤ -3.5), consider anabolic agents such as teriparatide as initial therapy. 1
• Plan treatment duration for 3-5 years initially, with continuation in patients who remain at high risk based on repeat DXA and clinical assessment. 1

Rehabilitation Protocol

Early Phase (First 2 Weeks)

• Begin early postfracture physical training and muscle strengthening exercises within days of injury or surgery, focusing on range of motion while avoiding overly aggressive therapy that may increase fixation failure risk. 1, 5
• Initiate mobilization with weight-bearing as tolerated, avoiding above-chest-level activities until fracture healing is evident. 1

Long-Term Phase (Months 3-12+)

• Continue long-term balance training and multidimensional fall prevention programs, as these improve bone mineral density, muscle strength, and reduce fall frequency. 1, 5
• Maintain systematic follow-up to monitor adherence, as long-term compliance with osteoporosis medications is poor (often <50% at 1 year) but substantially higher (up to 90%) when coordinated through a fracture liaison service. 1, 3

Non-Pharmacological Interventions

• Ensure adequate calcium intake of 1000-1200 mg/day through diet and supplementation when necessary, combined with vitamin D 800 IU/day—avoid high-pulse dosages of vitamin D as these paradoxically increase fall risk. 1, 3
• Counsel on smoking cessation and alcohol limitation (no more than 2 drinks daily), as these independently increase fracture risk. 1
• Educate patients about disease burden, risk factors for subsequent fractures, expected treatment duration, and the critical importance of medication adherence. 1

Critical Pitfalls to Avoid

• Never dismiss a vertebral fracture as "just traumatic" in patients with osteopenia—the trauma revealed underlying bone fragility requiring treatment, as these patients have 3.4 times the risk of hip fracture and 12.6 times the risk of new vertebral fractures. 6, 7
• Do not delay osteoporosis treatment while waiting for "perfect fracture consolidation"—initiate bisphosphonates immediately to close the osteoporosis care gap, as secondary fracture risk is highest in the first 6 months. 3, 5
• Avoid discharging patients without a concrete plan for osteoporosis evaluation and treatment, as up to 65% of vertebral fractures are asymptomatic and only one in three is diagnosed clinically. 1, 6, 4
• Do not assume patients will follow up independently—systematic coordinator-led follow-up increases appropriate osteoporosis management from 26% to 45% within 6 months. 1
• Never use calcium supplementation alone without vitamin D and pharmacological therapy, as calcium alone has no demonstrated fracture reduction benefit and may cause gastrointestinal side effects. 1